The Ultimate Guide to Male Hormones & Men’s Health

Hey, it's your friend Mel and welcome to the Mel Robbins podcast. Today, you and I are learning all about male hormone health from one of the greatest medical experts alive today, Dr. Michael Eisenberg. Dr. Eisenberg is the head of Stanford's male reproductive medicine and surgery program and today he is here in our Boston Studios to teach you and the men that you love, everything you need to know about men's health. We're going to cover low testosterone, erectile dysfunction, fertility issues and so much more and I just have to tell you, I have been dying to do an episode on male hormone health for over a year. This is something that my husband, Chris and I have been talking about. We've been talking about testosterone for two years. Should Chris go on it? Should he not? I have his permission to tell you all of this. Well, today Dr. Eisenberg is here and he says, look, reproductive health for men, it's more than having a healthy sex life. It's more than being successful at trying to have a baby. Men's hormone health is a window into his future health. So if you have a man in your life who just doesn't seem like himself anymore, if you've been badgering him, like I have, saying you should go talk to your doctor, you don't seem like yourself. If you've been on the receiving end of badgering from your partner who's pushing you to go talk to your doctor because you don't seem like yourself, that's why we're doing this episode. Dr. Eisenberg is going to answer all your questions and he's going to help you and your partner understand what may be changing, what deserves attention and what the two of you can do to help the men in your life be happier and healthier at any age. This is the ultimate guide to male hormones and men's health. I am so excited about the topic. I'm excited that you're here with me. It's always an honor to be together and to spend time with you. And if you're new here or if someone sent this episode to you like I'm going to send this episode to my husband, I just want to welcome you to the Mel Robbins podcast family. In fact, I should welcome you. If you're a man and someone you love sent this to you, you're going to love this. You're going to love Dr. Michael Eisenberg. You're going to love everything we cover today because this episode is the ultimate guide to male hormones and men's health. Dr. Michael Eisenberg is the absolute authority on the topic. He's a professor of urology at Stanford University. He leads Stanford's male reproductive medicine and surgery program and serves as the director of the International Azo Spurmia Center, which is basically a male infertility center. Dr. Eisenberg is a world-renowned board-certified urologist and surgeon who specializes in men's health, low testosterone, erectile dysfunction, sexual dysfunction, and male infertility. I cannot wait to dig into this topic. So please help me welcome the incredible Dr. Michael Eisenberg to the Mel Robbins podcast. It's a pleasure to be here. Dr. Eisenberg, I really appreciate you getting on a plane and taking out time from your extraordinarily busy schedule, clinical practice, overseeing your fellowship, teaching residents, all the research that you're doing to be here. So thank you. You're very welcome. Let's just jump right in. I know what I am hoping to get out of this, but I would love for you to speak to the person who is listening, who is here with us right now and share with them based on everything we're going to cover today related to male hormone health and men's health in general. What could possibly change about their life or the life of a guy that they love if they take everything to heart that you're about to teach us? What are we going to learn? I think we're going to learn quite a bit. I think that these are topics that aren't really discussed a lot. I think people don't understand them a lot. I think there's a lot of embarrassment about them. I think there's really an opportunity to learn and improve. I think that all these things are so fundamental, not just to overall health really, but to the quality of life. That's mostly what we're talking about. I think there's real opportunity to improve just enjoyment, benefit, and then longevity as well. I think these are things that people don't necessarily think about or do as much with, but if you understand it really, you can empower things. I think people also understand that there is a lot that they can do. They have a lot of agency with a lot of these things, and it starts with education, which I think is one of the great things about this podcast. Dr. Eisberg, for the man who is listening right now, who got this episode sent to them by somebody who cares deeply about them, what do you want him to know about what we're going to talk about today? Well, you're going to learn everything you wanted to know about hormonal health, sexual health, reproductive health. You'll learn all the things that you can do, how to get tested, why to get tested, why not to get tested. Getting tested for hormones, we're getting tested for sexual function, reproductive function, and you'll just have a greater appreciation for how impactful this can be for quality of life, longevity, everything. Well, I just need to say up front, I have my husband Chris' permission to share information because I'm just going to go on the record, and maybe I'm going to sound like a giant dummy, but it's not until I hit Perry, Menopause, and now I'm fully in Menopause that I even started to think about male hormone health. I'd love for you Dr. Eisberg to start by just setting the table for us, what is male hormone health, and what do you want us to know about it when you think about the bigger picture before we dive into specific questions? Yes, so I think it's just sort of optimum hormone levels, and I think when we think about men, the main one we talk about is testosterone, and it's important to know that the normal range of testosterone is quite wide, 300 to 900 nanograms per desolate, and so when we think about that, there's some men that are on the lower end, some men are on the higher end, some men are square in the middle, but it's a very wide range because normal is a little bit different between everybody, and it's so important, we're obviously going to talk about all the things that it does, quality of life things, overall health things, functional things, so I think that having that understanding I think is really fundamental. What age do men start to see changes in testosterone? So as we go through puberty, testosterone increases, and it probably peaks, probably somewhere between 20 to 30, and then every year thereafter it goes down maybe 1% a year. So if you look at epidemiologic data of populations, men that have low testosterone, so kind of below those cut points below 300 or so, maybe men in the 40s or probably 50s, maybe about 10, 20%, you go in the 60s, it goes to about 20%, 70s, 30%, then the 80s is about 50%. So the kind of statistic that's always talked about is over 50, about half of men have a low testosterone kind of a serum number. So that's when men should start to think about that is something they should get screened for. So I just want to make sure I understand the math because you just spit out a lot of numbers right there. So when you were saying 10%, 20%, 30%, and then you're going 40, 50, 60, were you basically saying that your testosterone kicks in for puberty? And is it relatively stable until you hit your 40s or 50s, and then you start to slowly decline? Is that what's happening? And that's normal. It is normal. I think it peaks somewhere between 20 to 30, and then it goes down a little bit. So it's not usually kind of a steep drop off, but it does slowly go down in it. There's different factors, age is probably one, but also, you know, our metabolic health atoposti, like how much weight we have, I mean, all these things will impact it. What are the signs or symptoms that you may have low testosterone? So I think they're sort of quality of life thing. So low energy level, low sex drive, you know, poor mood, poor sleep, poor concentration. I will certainly admit that these are somewhat non-specific, but if you're having these, you notice these a little bit more, they're bothering you, your partner notices them. I think certainly get screened for low testosterone. And then again, some more health metrics. So like low blood counts, so-called anemia, I think that's something that can be assigned. If you're found to have low bone mineral density, with no other explanation, get screened. And then again, if you have a history of chemotherapy, radiation to the testicle specifically, but the symptoms that we'll see, again, these sort of low energy level, those are typically things sexual dysfunction or rectal dysfunction. Those are things that we want to think. Does this guy have low testosterone? Let's check it. Well, I'm thinking about it from the partner standpoint, because as you're listing those things off, I was kind of going like, okay, check, check, check. At least not right now, but certainly about five years ago, Chris is very open about the fact that he was struggling with depression, and just was not himself, like very low energy, very shut down, very low sex drive. He wasn't irritable, but just seemed down. And so it's helpful to hear even though those are sort of general things that you may see as a change in your partner, but it's helpful to understand that they can point to something deeper. Right. Exactly. Do you often see patients alone or do the spouses drag them in? I'm always so excited to see the spouses. I'll say the majority of men come alone, but anytime I see the spouse, whether it be for testosterone-related discussions, whether it be for like sexual dysfunction, fertility, I always shake the hand of the spouse, and say I'm so glad you're here. This is a team sport, right? And so then I think that level of engagement I think is very helpful and I think I know that the wife is going to be, or the partner is going to be a huge advocate that's going to help us get through this and be more likely, it will get treatment success. Well, Dr. Eisenberg, what are the benefits of going on testosterone? It can help with energy level, you know, vitality, I think it can help with some things and not others, but we do see that consistently, we see improvement in sexual function. So again, such a powerful aspect of quality of life, but it can help with libido, it can help with erectile function. So those are all things good, you know, peanut health, keeping that, can help with bone mineral density, you know, men that have low blood counts, it can help with that, it can improve lean body mass, it can improve metabolic health. There have been some studies that followed men that were kind of pre-diabetic, and those men that were on testosterone had a lower risk of developing diabetes. So it can kind of maintain, again, longevity in that regard as well. So I think also sometimes men talk about increasing their motivation, making them more active. What about some of the things related to mood, or related to energy, and the things that we see in the negative in our partners, and we're like, "Wow, you don't seem like yourself. Do you see a boost in mood and muscle development, and just all the other things?" Yeah, so certainly it can help with, you know, mood, certainly patients that get a good response. They do talk about that. People talk about having sort of better cognitive load as well. There's different ways that we give testosterone, and so some men come to the clinic every few months for basically a shot or some new installation of whatever treatment we're doing, and they say that I needed it because I can't sleep as well, I can't focus at work, and then as soon as they get on it, they see that improvement. Again, these are men with low testosterone, so this is the reason they're having these symptoms. And so we see that. And also just lean body mass can help with strength, all those things. You know, we do have measurable improvements in the patients that I see, but also we've done very good trials that do support this improvement. You know, I don't know if this is something that happens in your 50s, and I don't know how old you are, doc. But I notice that when you hit your 50s, I'm going to be 58 in a couple of weeks. Suddenly, people start talking about testosterone. It starts on walks that women have together as they're talking about their partners. But I've noticed more and more people talking about it. And one of the first things that I was really wondering about is how often should men get their testosterone checked and at what age? Yeah, there's many different reasons that we give it. Some men, they don't produce normal testosterone because of some medical condition. So for example, some men with like, testicular cancer to lose one or both testicles, the levels can go down. If there's a history of chemotherapy, that can affect it. Some men with academia, they're very low blood counts. We worry about that. Men with low bone mineral density, that's another warning sign. So I think if you're having symptoms of low testosterone, so again, low energy level of sex drive, mood sleep, erectile dysfunction, these are also reasons it sort of clue and could this be testosterone? Could this be hormonal? And then you can have a check. So just like you go to your doctor and getting checked for blood pressure, cholesterol, blood sugar, I think it's a simple test to add on because you know, our levels do change a lot. So getting checked, I think sooner rather than later, is a reasonable thing to do. Probably you know, starting maybe 40, 50, but again, if you have some of these other things you want to check much, much earlier. And is it just a blood drawer? How do they check testosterone? That's exactly right. It's just a blood drawer. So our levels do change based on time of day. Okay. So usually we check it in the morning, ideally in the fasted state, although you know, honestly in my clinic, I'm not so particular about that, but I say 9 or 10 in the morning. And then we usually also want to repeat it. So if we get one low level, we'll do another one. And if those are both confirmatory and also symptoms, then we talk about supplementation. The second you said the thing about testicular cancer, I'm like, wait a minute, my husband had a herniac surgery related to, I don't know the technical name, the balls. So he only has one ball. And I'm like, whoa, that might actually be the reason why he has low testosterone. It could be Dr. Eisenberg. Why are we so embarrassed to talk about this? I don't know. I think that, you know, it's gotten a lot better. And I think to your point, I think people are more and more comfortable talking about testosterone, just like 20 years ago when Biagra came on the market for rectal dysfunction. I think that made people a lot more comfortable. And I think there are spokesmen now and people are very open about being on testosterone and all the benefits. But I think there's also just this feeling of shame a little bit and guilt sort of concerns about their own masculinity, that if their body can't produce enough or something wrong. And that's absolutely not the case. There's a lot we can do. It's very common to have these lower numbers treatment is certainly underway. But what I was saying with, if you lose a testicle, oftentimes the other one is able to compensate, it's able to grow again, depending on what happened and when it happened. It's like a super testicle. Yeah. So one testicle do just fine, but obviously, you know, it's a paired organ. So, you know, ideally, there's both and if there's only one, sometimes it's not. Wait, what does that mean? It's a paired organ? Well, there's two of them. Just like we have two eyes. Yeah. Two lungs, two kidneys. So we have two testicles. It's obviously super fundamental for our species, right? It's involved in reproduction, but testosterone production is also such a fundamental role for the testicle and making us men. So there's some redundancy in the system for that reason. I'm going to sound like a real idiot. I have almost embarrassed to ask you this question. Is testosterone produced in the testicles? Oh, primarily, yes. Okay. So the testicle produced most of the testosterone are adrenal glands, which are these little endocrine glands that produce different hormones that just on top of the kidneys, they produce a tiny fraction, but most of it, 90%, or more, is produced in the testicles. Wow. We love to ask a few questions about how specific things can impact your levels of testosterone. How does poor sleep impact your testosterone levels? Here we go. Okay. You've got a sign. Oh, cool. Poor sleep. Yeah. Poor sleep affects testosterone through a few mechanisms, but primarily it really just blunts our normal kind of feedback. So the way that we produce testosterone is the brain sends signals to the testicle, and it kind of senses when there's enough testosterone, so there's just a labyrinth feedback loop. And poor sleep really blunts hormonal function just broadly, but certainly involving testosterone production. And so without this sort of normal rhythm that we see, you know, higher levels in the morning, kind of gradually kind of calming down as we go to sleep. Without that, basically, there's just a general suppression of testosterone. So that's one of the main mechanisms, certainly men that are very sleep deprived. You see that, but even if you're just not getting enough sleep on a regular basis, you know, ideally, seven to nine hours is ideal, but these men that kind of say they only need a little or they're, you know, four to five hours a night, we do see that suppression, shift work, all these things that disturb just normal circadian rhythm can affect it. Do you see any kind of connection with somebody who may struggle with sleep apnea and the low testosterone levels? Absolutely. Absolutely. You know, in some ways it can kind of sort of feeds back on itself because low testosterone itself is thought to be associated with sleep apnea and sleep apnea leads low testosterone. So in some ways, it's sort of circular, but we definitely see that association. Interesting. And very helpful. How does excess body fat impact your testosterone levels, Dr. Eisenberg? All right. So testosterone is made in the testicle. And then in the peripheral tissue, some of it is converted to estradiol. And that's one of the main ways that, you know, our body regulates testosterone production because estradiol is, you know, you kind of think of it as a female home, but certainly men have a lot. It's very important for our function as well for bone health or sexual health. But it also impacts primarily the feedback mechanism that, you know, our body uses to regulate testosterone. And a lot of that conversion of testosterone to estradiol happens in fatty tissue. So the more fatty tissue there is, the more conversion to estradiol. So you kind of see this is sort of a leads are pulling out of testosterone from circulation. So if we're too big, it can affect that. And also excess body weight, a lot of it can be insulation down the testicles, the testicles are outside the body because it need to be a little cooler. Mostly it's for sperm production, but it can also affect hormonal health as well. So having excess body weight, this poor metabolic state impacts just normal hormonal regulation. So kind of blunt the normal response that we see for normal production. If you see a patient go on one of these life changing GLP one medications and they start to lose a lot of weight. You typically see somebody's testosterone levels rise when that happens. anecdotally I have seen that. I think losing body weight from caloric restriction, I think, not if you starve yourself, but if you, you know, good diet exercise, if we see that, and they lose weight, we can also see improvements. Certainly, you know, GLP ones have seen that bariatric surgery, reliably increases testosterone. So I think anyway you can lose weight, you know, kind of getting an ideal body weight. I think that's really going to be crucial. Anything is good for your heart, it's good for testosterone. That makes a lot of sense. How does chronic stress, the number one word that we're seeing right now, Dr. Eisenberg from our audience globally is exhausted? And I'd love to know how does chronic stress impact testosterone levels? Yeah, we get stressed from so many things in our life, like work, home, everything. Spouses? Spouses? Yes. Well, I'm speaking for myself. I feel like I really need to lift Chris up now. Yeah, I don't want to get in trouble, but yeah. If there's too much stress, we get this cortisol release in our body. And that basically just blunts the normal testosterone response. You know, again, it's always easier to say more sleep, less stress, for example. But if you take that to heart, if there, you know, there's ways that you can do that to try and lower the stress in your life, you can see improvements in testosterone levels. I think it's really interesting that you use the word blunt, that you can be doing all the right things, getting good sleep, moving your body. You have a healthy body weight, but if you're under chronic stress from a job or care giving or you're going through something very stressful in your life, that the rise in cortisol and that, like, fight or flight, blunts the testosterone that's there. Can you explain a little bit more about that? Your body is just prioritizing survival, right? And so if there's something else going on and wants you to survive, like if the tiger comes around, right? Nothing else matters. You need to get out of there. And so I think we see the same thing with testosterone, hormonal health, reproductive health. It's just sort of deprioritized. So you become in survival mode more than longevity mode. And so that's exactly the response that we would expect. Well, it's helpful to hear from a doctor. And the reason why is, I think a lot of men really feel a lot of pressure to be providing, to be taking care of their partner, their family, to be earning money, to be out in the world and be successful, and whether that societal or self-imposed or both, that men are under a lot more pressure and stress than, I think, a lot of us realize, because a lot of them bear it more quietly. I feel like, since guys tend not to be that great at talking about the things that are really weighing on them, you're the one that's seeing how that can cause health conditions in somebody. Yeah, I mean, I think for these conditions, we're talking about, it's often the first time they've ever gone to the doctor, the first time they've ever had really, anything's kind of caught up with them, to some extent. Everything's just sort of worked, right? I mean, the patients that I see, you know, in Silicon Valley, Taipei, they've been very, very successful, you know, the top jobs, everything is going really well. And here, you know, all the sacrifice they've made in their health, getting little sleep, bearing this unbelievable stress for a new startup or what have you. Now they start to see some of these things fall apart, hormonal health, sexual health. They feel guilty, they try and, you know, kind of rationalize it a little bit. But, you know, I can take a step back and just giving them sort of these actionable things that can be done to try and reset things, I think, can be very powerful. It's super helpful. I'm even thinking about like some of my male relatives who are all in the cattle business, or farmers or machinists or long haul drivers or police officers and just the stress of those jobs too, that you bear, it's interesting to really stop and consider how that's having an impact on your hormone health and on all your sexual health. So, I appreciate you explaining it in detail. Dr. Eisenberg, can you talk about the connection between depression and testosterone? So, depression and low testosterone, I think, are very closely linked. And this is one where we think low testosterone itself can impair mood, but also depression itself can also impair testosterone production. So, when we think about how that would happen, I think there's a few mechanisms. But, you know, really, primarily again, it leads to the same sort of lack of ability of the body to respond to normal stresses and normal circadian rhythms. And it just sort of blunts that hypothalamic, which is, you know, a region in the brain that stimulates this other region called the pituitary, which then stimulates the testicle. So, all that signaling is basically lost a little when these men have depression. And the other thing I think to think about depression is a lot of times there are very effective treatments for it. But those themselves, some of these medications that we talk about are also very impactful on testosterone. Meaning they make it rise? They make it go down, unfortunately. Oh, no. So, you may be treating the depression with a medication that sort of lifts the fog. Yeah. But at the same time, it's lowering testosterone, which can continue to make you feel like you're moving through sludge as you go through your day. Yeah, it can affect hormonal health and then sexual health as well. So, it is. Wow. So, it's important to understand that these things can coexist and that it's important to realize that the treatments for one don't necessarily take care of the other and vice versa. Right. Exactly. So, you should think about them in some ways independently. And so, I have patients that do have depression are on treatment for it and we're also treating their low testosterone. And together, hopefully, we can get them to a good place. Excellent. Super helpful. Let's talk about the connection between alcohol and testosterone, Dr. Eisenberg. So alcohol also is associated with low testosterone. And what alcohol does really at every level is it blunts the body's response to the feedback of regulating normal levels. And then the signal going down to the testicle, the testicle's ability to make testosterone. All those things are blended by too much alcohol. So, moderation. If patients are telling you they drink a lot, it's good to try and regulate that. The men say they have five drinks a night, seven drinks a night, which is a lot, so which is a lot. Yeah. Okay. That makes sense. So, if and you've seen that when people curb the drinking, the testosterone can rise. It can go back up. You know, it's, it's never quite as easy as saying stop and they stop immediately. But, you know, gradually cutting down, getting in a program, I think we do see improvements for sure. I think also beyond just testosterone, really, it's going to improve their overall health. That level of substance abuse and alcohol dependence, I think, is going to have many, many impacts. And so they do feel better when they get through the other side. Dr. Eisenberg, thank you so much for being here. I am learning so much. I know my husband is going to be grateful that you're answering these questions, too. I want to take a quick break so we can give our amazing sponsors a chance to share a few words. And I know you're thinking about the men in your life. I knew that I was going to send this to my husband, Chris, but I'm also going to send this to my brother, Derek. So get ready, Derek. This one's incoming. And don't you go anywhere when we return Stanford's Dr. Eisenberg is going to dive into everything you and your partner need to know about a reptile dysfunction. That and so much more when we return to stay with me. People are more and more comfortable talking about testosterone 20 years ago and by agrar came on the market for a reptile dysfunction. And I think there are spokesmen now and people are very open about being a testosterone all the benefits. That was Stanford's Dr. Michael Eisenberg. And today you and I are getting the ultimate guide to male hormones and men's health. So let's just jump right back in. So guys that end up doing testosterone or going on testosterone. It's literally like they're in a multi level marketing organization. They're so passionate about it and wanting everybody to get on it. And I've been very surprised because my husband has been very resistant to even considering testosterone. He's just started talking to doctors about it. And so I would love to dig in a little bit to some of the things that at least he's concerned about because I'm sure a lot of people are concerned about it. I asked him what's your concern about starting it based on what you know? And he said that with injections, I don't even understand what this means, Dr. Robert. That with injections, it's a lot of oil intake for the next 30 years of my life oil intake. And that the long term effects of taking it for that long of a time have not been researched. These were his two concerns, the long term effect and that it's a lot of, I don't know what oil intake. Maybe that was a mistake. Is it oil? It is oil. So the injectable testosterone, he's exactly right, is an oil based medicine. Okay. So you basically inject kind of this oil in the muscle and you can do it in different ways. And I usually teach men to do it in their thigh if they have a partner who can do it in the buttocks. But it is an injection that's done a regular basis for injections. You know, the standard is probably doing every two weeks, you know, you do kind of get this peaks and valleys. Some and feel that sometimes we shorten the duration, they do it once or twice a week. But testosterone therapy has been done for decades and decades. So it's very, very safe. Now there's different ways to give testosterone. So some of them certainly don't like the idea of injections. So they're longer acting injections, it could be that a few months. So that may be more appealing for him. There's gels that you could put on, you know, every day. So again, there's no needle at all. There's different testosterone pellets. It can be put underneath like, usually under the skin and the hip area is classically where it's done. So again, there's not any needles with that. Has the pellets been tested by the FDA because I know that we've had medical experts come on and talk at least with when it comes to women's hormones, there's been several medical experts that have come on to say they don't like the pellets because they haven't been approved by the FDA. But that was a couple of years ago. So maybe things have changed. Yeah. For the men it certainly has. Yeah. There's no FDA approved testosterone for women. Gotcha. So that I think, hopefully that's evolving. I know there's a lot of advocates for female health that have seen, there is some good data that it can help for men it is approved. And there's also a testosterone oral tablets as well. So there's many ways it can be given. I think most commonly it is injections. Okay. What are the negative side effects, Dr. Eisenberg of testosterone? Testosterone has been tested by the World Health Organization as a contraceptive. So it can actually lower sperm production. Does that pretty reliably? Probably 90% of the time. Wait. I'm confused. Hold on a second. You said testosterone is a contraceptive? In men it is. Yeah. It lowers your sperm count. Wouldn't it increase it? Well, you'd think that. But there's many reasons that it doesn't. So if we think about how the body makes testosterone, we talked about the brain signaling the testicle to make testosterone. And then there's a feedback loop. Your body knows when it needs testosterone to kind of sending the signal down. So when you take testosterone exogeneously, whether it be injection, gel, any of the different methods. What is it? What is it? Oh, exogenous. So outside testosterone. Okay, got it. Okay. enough testosterone. I don't need to make any more. And so if the brain doesn't signal the testicle to make testosterone, it stops doing that, but it also stops making sperm. So those signals are very, very closely related. In addition, in the testicle, the testosterone levels are probably about 100 fold higher. So if your normal testosterone is kind of swimming around in the blood at 500, let's say in the testicle, it needs to be, you know, 5,000 or much higher than that even. And so when your testicle doesn't see this super, you know, 5,000, 50,000 level of testosterone, then you're not going to make sperm efficiently either because you need those high levels of testosterone for efficient sperm production or shrimadogenesis. So there's sort of two different methods. So low testosterone and the testicle and then not that signal to make sperm. That's what happens with testosterone. So low sperm count is one negative side effect. What are some other potential negative side effects from taking testosterone? There can be skin changes, can leave the oil skin acne, can leave the hair loss, breast growth as well. This testosterone is converted to estrogen, which we do need for normal, you know, function, but if estrogen levels get too high, there can be some breast growth. So sometimes we see that as well. Now there used to also be some concerns about prostate health and even heart health with testosterone, but there was a very landmark study of about 5,000 men called the traversed trial where men were given testosterone, men were given placebo. So you know, kind of a dummy gel and then just followed to see if there are higher risks of any of these adverse outcomes. And it turns out there weren't. So we used to worry that if you add testosterone to men, they're going to see more levels of prostate cancer. That was debunked. And then there was also some early due signals that men on testosterone are higher risk of like heart attacks and strokes. Also with the study we didn't see that. So that's also been debunked. So the FDA is actually going to update guidance on prescribing and some of the warning labels to remove those because I think that was also a barrier similar to female hormone replacement. So I think hopefully that'll help a lot of men as well. Dr. Eisenberg, is it important that you go see a urologist or your general practitioner and that a doctor is overseeing this? It's so crucial that a doctor oversees this because I think it can certainly be abused or misused or misprescribed. You can give anybody testosterone, but you really want to make sure you're giving it to people that need it. Otherwise you're just exposing them to all the risks and none of the benefits. We've seen from our best evidence that if your testosterone is normal and you're given testosterone, it's very unlikely to help any problem you have. Wait, say that again. It's such a crucial point that if you have a normal testosterone and you're given testosterone, it's unlikely to help with some of these other symptoms. You know, that people would come in for sexual dysfunction, for example, for performance. People think that if I take testosterone, I'm going to be a better version of me. And that's not the case. There have been studies in the military thinking about testosterone as a performance enhancer. And while it did help with lean body mass for, you know, kind of military sort of hero exercise, these men were doing whether they got testosterone or whether they got placebo, their performance was similar, their recovery was similar. So if you have normal levels, you probably shouldn't be on testosterone. And so I do worry that some of these clinics that'll just prescribe it, right? That's how they make money, right? It's just giving these prescriptions upselling. If you don't need it, you shouldn't be on it because you're going to get exposed to all these risks that we talked about, right? Like hair loss, breast growth, you know, higher levels of, you know, red blood cell count, which can lead to clotting risk. I am so glad you're saying this because I just assumed that if you're a guy in your 20s, 30s or 40s and you want to look more ripped and you want to perform better in the bedroom and you want to be more energized, just start testosterone now and never even occurred to me that it might not do anything except for lower your sperm count, raise your blood count, make you lose hair. Wow. Yeah. Yeah. I think that's something that men need to be aware of that it's not all upside. And I think it's not for everybody. And so I think seeing somebody that understands all of our guidelines from the American You're Logic Association, the Endocrine Society, very thoughtful data driven approaches to this. And so I think that's really crucial. One of my husband's big concerns is that once I start this, I have to take this for the rest of my life. And so Dr. Eisenberg, once you start testosterone, do you have to take it for the rest of your life? So it depends for men that, you know, don't make their own testosterone. So for men like that have lost both their testicles or some congenital conditions where the testicles don't function properly. Those men do need to be on testosterone forever. But for these other conditions where men have some symptoms, low energy level, sexual dysfunction, found to have some lower levels, usually we started as a trial period. I think all the different societies recommend this. You know, we start testosterone. We'll check the levels to make sure you're in a therapeutic range. Sometimes we'll switch between formulation so we can get there so it's convenient. And if they see the benefit again, which a lot of men do, they want to be on it because they do see sort of a better version of themselves. But if they really don't notice any changes, then we'll just stop it. So after six months, after a year, they're not seeing those improvements, then we can stop it. Or if there's other reasons, you know, we talked about some of the causes of low testosterone, like obesity, for example. So if they can start testosterone, sort of reclaim their health, you know, lose some of that weight, then the body's own production can kind of boost up and then we can kind of wean them off. Their body takes over and hope for there at a normal level after that. How do you bring this up with your partner? Because I can already hear the send, I can hear somebody copying the link to this episode. Is there listening to it right now and texting it to their partner? But how do you bring this up? All my girlfriends and I are talking about this and the fact that we have all diagnosed our husbands with low testosterone. What's the most empowering and compassionate way to bring this up? It's a good question. I think everyone's going to be, you know, kind of individualized. But I think there's many ways to sort of approach the subject. One is we've talked about these symptoms. It could be testosterone. Have you thought about bringing it up to Dr. Smith next time you go in this year? Or I heard the super interesting podcast about testosterone. It sounds like it's really not just linked to some sexual function, but it's also linked to longevity. And I love you. I want you to be there forever. So if you haven't had it checked, it sounds like it's easy enough to do. Maybe we can do that. So I think kind of this time with health, with strength, you know, in your 30s, everything's super easy to do. But as you kind of get older and older, normal household chores, bringing in a bad groceries, everything gets a little bit harder. So I think an easy way to get checked and maybe there's something that can be done to help with some of those things too. Amazing. Dr. Eisenberg, thank you for explaining everything that you just did about hormone health testosterone. I want to switch gears and talk about a topic that can be really difficult to talk about, which is erectile dysfunction. What is erectile dysfunction? Erectile dysfunction is the consistent or recurrent inability of a man to attain or maintain an erection sufficient for sexual activity. How common is it? It's so common. I think that, you know, when men come in, they think they're the only one affected. But if you look at studies, there's a famous study called the Massachusetts male aging study done here about, you know, 20 years ago or so, that shows that if you look at men over the age of 40, over half have some trouble with erectile dysfunction. Over half? Over half. And it increases every decade of life. So men in the 40s, about 40%, 50%, 50%, 60%, 60%, 70%, 70%, have some trouble with erections. And even men, you know, get younger. It kind of goes all the way down the other range too. So, you know, men that I see in their 20s, 30s, probably 15 to 20%. So it's a very common issue. What causes erectile dysfunction? There's a host of things. So ultimately, you know, what erections are as blood going into the penis and getting trapped there. And I think it may be helpful just to -- Sure. -- We can look at a model here. Okay. So, if you can kind of see this. So this is the erectile body. There's a urethra's on the bottom here. So this is where blood actually goes. So blood goes -- On the top of it? -- On the top. Okay. So these are the erectile bodies. These are what engorges with blood. Yep. And essentially what happens is when you get stimulation, whether it be, you know, visual, auditory, touch. Yes. There's many ways it can be done. Absolutely. You get, you know, different neurotransmitter release, nitric oxide release, which releases this other chemical called cyclic JMP, which then causes the blood vessels in the penis to die late, to open up, to let more blood in. Okay. And then that's what leads to erection. So anything that can affect blood flow anywhere in the body can affect in the penis. So for example, smoking, diabetes, high cholesterol, high blood pressure, all the things that we think about can affect like heart problems, can also affect blood flow in the penis and causing that. Trauma is also notorious for doing that. So for example, like prostate cancer surgery can affect a lot of the main nerve supply to the penis. Some bike saddle seats, for example, can also put pressure on some of the main nerves that conduct in the penis. Really? Bike saddle seats? Yeah. All the cyclists are now going to be mad at you. Well, I think for some men, I think in general, you know, anything that's good for your heart is going to be good for the penis. You know, it's sort of one of my mantras. So usually maintaining a good cardiovascular health is important. But for some saddle designs and some men, it can actually put a lot of pressure on some of those nerves and some of the arteries to the penis. And over a long period of time, not everybody, but maybe 20, 25% of men do notice numbness, pain and erectile problems, especially after long ride. So something to be aware of as well. How do men feel when they're experiencing erectile dysfunction? I mean, erectile dysfunction is such a profound effect on a man. I mean, they feel inadequate lack of masculinity. They feel a sense of guilt like they've done something wrong. You know, if they're in a relationship, they feel like they're contributing to marital problems. They sometimes like withdraw a little bit. So we see that can lead to depression. Again, these feelings of inadequacy. So ultimately, it's a quality of life function. And you know, reproductive at young age, but towards the end, it's sort of this way of intimacy and connection with somebody. And then when you lose that, when you see that you're the issue, when you feel like you're the issue, you kind of feel hopeless. A lot of men are not comfortable talking about this. They don't realize all the things that can be done. We see all these problems. Well, it's an important thing to stop and really think about because when I went through parimenopause and menopause, I absolutely did not feel like myself. I did not feel attractive. My body started changing in ways that I did not like. And it certainly impacted how I felt about myself. But listening to you, I'm sitting here thinking, but my vagina still worked. I mean, I might not have liked what my body felt like, but I could still be intimate with Chris. And when you really stop and think not just that your body no longer feels like it's your own, and you can't count on something that you have for a lot of your life. So I can understand that piece of losing control. But also feeling like you can't perform something that's one of the most awesome things about life with your partner. Yeah. I think that's exactly right. I think and it also something that it just separates yourself from your partner as you're going through this huge problem. One of the ways he used to connect is now lost. And some of these men feel that it's their problem and there's nothing that can be done. I think this hopelessness is something that I definitely hear about a lot. What do you want women in particular to know if you are with somebody who is experiencing erectile dysfunction? I think there's two things. I think that one is it's very common. So just know that man is not alone. And then I think the other thing is that there's a lot that can be done. I always like to tell men as long as you have a penis, we can always make it hard. So just let them know that there's therapies that are available. As long as you have a penis, we can always make it hard. Yeah. Really? That's right. Yeah. You can fix anything. Anything. Yeah. There's things that we do. So you have to be willing to be very aggressive, but there's always a therapy. Wow. Dr. Eisenberg, I just want to thank you. This is the kind of information that every couple needs to hear. I really appreciate how you're sharing it, how compassionate you are. I feel empowered. I know as you're listening right now, you feel empowered because when something changes in your sex life, it's so easy to take it personally and to avoid talking about it or to assume that something's wrong with the relationship or that there's nothing you can do. And I'm really learning that there is always something you can do. Now, I need to take a quick break, but please take the time and share this extraordinary guide to male hormone health and to men's health with somebody that you love. It might be your partner. Maybe it's a male friend. Maybe it's one of your friends who doesn't have a clue why their husband is off a little lately. And don't go anywhere because after the break, Dr. Eisenberg is going to tell you exactly what all men need to start doing today to protect their hormone and sexual health as they age. Stay with me. Yeah. Really? That's right. Yeah. Anything. Yep. That was Dr. Michael Eisenberg talking about male hormone health. He's a professor of urology at Stanford. And today he is sharing the ultimate guide to male hormones and men's health. Let's talk about what can be done if you're experiencing erectile dysfunction. The first thing we want to do is look holistically at their health to sort of understand what medications are on because there are some medications that can affect it. Sometimes we see blood pressure medications are notorious for causing problems. Sometimes anti-psychotics, anti-depressants. Those are all things to think about. Maybe talk to some of their other doctors. That's one of the reasons I do get on the phone with referring providers sometimes. And then look at their health, too. What are they doing? Are they exercising? What is their diet like? What's their BMI, their body mass index? Because these are things that we could potentially correct. Once we've done that and everything's optimized as much as possible, we talked about some treatments. So the first line is going to be pills. And I actually brought some here. Just so everybody knows. So these are called phosphodaesterase inhibitors. Who? So the things that we hear about, like biagrostyldenifil, bardinifilulavitra, tidalifilcialis, these are the ones that are on TV. So these are the pills that help with erections. And basically, are they all the same by a different name or do they work differently? They're sort of cousins. So they have the same mechanism of action. The molecule is a little bit different. Some of their chemical properties are a little different. So some last longer in the body, some act a little quicker. So depending on what the goals are, we prescribe some in different conditions. And some men do respond better to one the other. Sometimes men have different side effects with all of them. But again, they're very, very similar. But then kind of react a little bit differently. Well, we're going to take them one at a time. But do all of these medications impact blood flow? Is that basically what they're doing? That's basically what they do. So the way that erections work again is, you know, we get the stimulation, which leads to this base of violation or opening up the blood vessel. So one of the main signals for that is this chemical called cyclic GMP. And it's broken down. So what these medications do is prevent the breaking down of this chemical. So the more the chemicals there, the more the blood vessels they open, the longer the erection can last easier to get erection, all those sorts of things. Wow. Can you walk us through each one and just kind of tell us what the drug does and like, what's the downside to it? And like, why you would prescribe that one versus a different one? I don't know if that's a fair question. I don't like, I certainly won't turn this into an ad for anything. Yeah, I'm just going to come right out and say it. If you're a woman and you see these ads, a couple things happen for me. One is, where is the female version of this? Yeah. And the second one is, okay, if my partner starts taking this, is he going to like, pop a boner, like, immediately? And then I'm going to be running away from him. And now I'm going to have a different problem than him being depressed. He's going to want sex all the time. And so as a woman, I'm just like, now, sharing the stuff we say on a walk when we talk about this stuff. Yeah. That's a good question. No. In general, no, this is not going to give you a permanent erection. This is basically just kind of augment the partner's ability to get an erection when they want it. So it kind of helps it on demand erections, essentially. And it can't help with performance, you know, for performance anxiety. But also, again, when you're just not getting erections, when you need them, when you want them. Gotcha. So the first one was Viagra. You know, the way you take is about an hour before sex. For most of these, better take it on empty stomach. So hour before hour after you eat, makes it easier to get to keep erections. You know, it's also things to know about as some of the side effects. So most men do fine, but the rare side effects would be like headache, facial flushing, back eggs, like cramps indigestion or nasal congestion. So the way they work again is they open up blood vessels, mostly in the penis, but they can do it in other parts of the body as well. So you can get some of those side effects. But again, most men do fine. So I think Viagra is certainly a good one to start with, or Seldenafil. Cialis or Tidalafil is the other one. So this one lasts a little longer in the system. It's kind of marketed as a weekend pill. So for example, Viagra, the half life, like how long it takes to clear from our body. So half of it is out of our body in about six to eight hours for Cialis. It's probably 16 to 18 hours. So it just stays all around a lot longer. So if you take a pill on Friday, there's still some on Saturday as well. This also allows a daily dosing. So you can give them kind of a low dose medication every day. So it's sort of always there to help. Also been some studies that show that it may be cardio protective in some ways. It's not FDA proof for that. But there's emerging data that, you know, if men that are taking the kind of low dose, Cialis every day, the lower risk of cardiovascular events. And is that like, and I realize we're just kind of imagining what the connection might be. But do you think that's because if you're increasing blood flow to the penis, you're increasing blood flow everywhere. And that helps your heart. That's thought to be the mechanism. You know, the originally medications were to design as a treatment for blood pressure, a treatment for angina or chest pain. It didn't work that well at that. But they this was kind of an unexpected but very profitable side of it. What's happening? It's that that's growing. But this is okay. Exactly. So that's kind of the the thought about it that it's, you know, again, cardio protective by increased blood flow. But should also say these are observational studies. So they basically, you know, look back at who was on Cialis, for example, who was not and just compare them. And those are different groups. So just to say, this has not been studied kind of in the most rigorous medical trial that we could do. But I think it's at least sort of reassuring. Some men do ask, is this going to be safe? Am I going to have a heart attack when I'm on this? The data says that that will not happen and may even be the other way. And are there side effects to taking the longer-acting one? The same ones. I think the same ones that we'll see. Oh. And again, the low dose, maybe it's even better tolerated. So as a Stanford urologist, when somebody comes in with erectile dysfunction, what do you recommend? Well, if they've never been on any of these, and we can't correct anything further than they already have. And I think I usually start with one of these medications. Gotcha. A lot of times when men have seen me, they've already failed these. And so they're ready for second line and third line options. Oh. And what's the second line that you would do? So there's also medications that you can put in the tip of the penis that are absorbed by the penis. So if we go back to our model here, that sounds painful. I'm just going to say the tip of the penis sounds very painful to put something in. So just in the erythra, you can put this medication that's absorbed in. And it works in this same way as widespread. It's like a gel. There's like a little pellet, but there's also a gel, and it's basically just absorbed throughout the whole penis. It's a vasodilator, so it works in a similar mechanism to the pills that it opens up blood vessels. Men do describe kind of a tingling or a low grade burn, usually they get used to it, safe for their partner or any orifice, and that works probably 60 to 80% of the time. So that can also be pretty effective. Got it. And is that something you do, like before you're having sex, or you have to do it every day, or. It's on demand. So yeah, so about five or 10 minutes before you're going to have sex, it's something you want to do. Okay. So if those don't work, so the next option is injection. So the penile injections are another thing that can be done. So essentially you take a small needle, and I think in with the GLP ones, people are more used to giving themselves injections, maybe not the penis, but I think there's a lot more comfort in that. And it's a vasodilator you're putting directly into the erectile bodies, leads to this vasodilation. That works probably 90% of the time. 90? 90. Now what I'll say is that there is a huge psychological barrier to putting a needle in your penis. But if men are willing to do it, it's very, very effective. Wow. And you do it. It's like an on-demand thing. It's an on-demand thing. It's such an interesting story because the first time it was ever discovered and brought to sort of the medical world was by a pharmacologist, a national urology convention in 1980. And what he did is he injected himself in his hotel room. He went down to deliver the lecture and then lowered his pants and showed the audience. And beyond that, he actually walked up and down the aisles, inviting people to inspect it. And you can imagine sort of the level of his penis. Well, it is a audience full of penis doctors. That's right. That's right. You guys know what they look like. Yeah. But the amount of shame and fear that you would normally have doing something like that. But the medication is so powerful, it's able to sort of suppress that response. It would normally cause erections to go away. So it is a very effective medication. I certainly don't advocate men injection themselves and walking around naked, but just to say that it does work. Wow. That's, I mean, he's he's doing one for all the urologists and men out there. It's a very famous. But I, but most conventions are in Vegas. So when you said there was a urologist in a hotel room in Vegas injecting himself, I thought, where the hell is this? You knew where this is going. No, I didn't know where this is going. I thought it ended sort of like that hangover movie. No, I'm glad to hear that it was something that he was willing to not only try, but it had such a profound breakthrough that he was willing to remove the shame and show all of his colleagues that were at this conference. Yeah. It's a very important medication and a very important option that we give men. Wow. What made you want to go into your own? Well, I like the problems that we deal with when I looked at andrology specifically, so hormonal sexual reproductive health, thought there was really kind of a lack of treatments that were available. I think there were lots of research opportunities of trying to do better by these men. So I just found that really fascinating. Just the powerful impact we can have on their quality of life, their overall health sense itself. All that really, you know, got me excited about the field. That's really cool because it's an important and unique specialty. I've heard you talk about the connection between having sex and prostate cancer. Can you unpack that for us? Yes. So there was a famous study that sort of looked at this about 30 years ago now. And it said that the more you had a man ejaculates the lower the risk of prostate cancer. So really fascinating. So what they found is that men that ejaculated 20 times a month or more compared to those less had about a 20% lower risk of developing prostate cancer. 20% lower. So this is a study of about 30,000 men fall for about 20 years. And they saw this pretty consistently all the different ways they looked at all the different age groups. This has been looked at in other studies as well, 100 to 1000 men. It's been supported. So why this is? It's not certain. It doesn't seem to be tied to how a man ejaculates. So whether it be sex, masturbation, for example, all those seem to give the same trend. It's thought maybe you're kind of clearing toxins, you know, from seminal fluid, preventing crystal formation. I think mechanisms are not clear. We do see that association of 20 ejaculations a lot a month. You know, maybe for teenagers, it's a little easier, but you certainly as you get older, it can't get more challenging. So I don't want to prescribe that for everybody. It's something to do, but it's an interesting observation. And we know and then asked, can I masturbate too much? For example, this is sort of the study that I always relay that it's probably not harmful. Again, there's some studies say maybe it's even beneficial. The other thing I was going to say is that there's also been studies linking sexual activity and a number of ejaculations and orgasms to longevity as well. We've talked a lot about how sexual function is related to overall health. So it may be kind of a marker for that, but there have been studies that show that men that have sex maybe once or twice a week compared to men that have sex sort of rarely, you know, less than once a month live longer, live twice as long in fact. And this is again, looking at men and they're, you know, when they started observation kind of in their 50s, 60s, if you follow these men, they reported, you know, regular sexual activity, they live longer. And that may be, you know, having a partner, all that things were very beneficial to longevity. But I think it's also something to be aware of. So another reason, you know, maybe they get checked out is that in addition to sort of the the joys of sex, which obviously are numerous, I think when you think about longevity, which is a huge push now, I think in our culture, which is great, you can also see some benefits for that as well. Well, I'm glad you said the thing about relationships. Because it is true. And so many renowned medical experts have come on to talk about the connection between your relationships long term and the quality of your life. And that when you don't have great relationships, as you get older and loneliness kicks in, that that is devastating to your physical health. And so I'm really glad that you're also highlighting that having a healthy sex life, being able to connect intimately with another person, you're right, it's not only one of the great joys in life, but it is a sign that you have relationships that are meaningful to you on a consistent basis. Yeah. And that intimacy isn't just about the orgasm, it's about the quality of your life. Yeah. And that's so crucial. I think this sort of the study is always like to quote or from Scandinavia where they have these great population birth and death registry. So the famous one that I quote from Sweden, where they looked at what effect having a partner has on a man's longevity and mortality and having kids. And it turns out our ideal is a man that has a partner is living with their and kids are living with them. If you get rid of having a partner, the chance of that man dying goes up 60%. And if you get rid of kids, we see the same thing. If a man doesn't have any kids, compared to someone that does 60% higher risk of death. And if a man doesn't have a partner and have children, about a threefold higher risk of death. So I think to your point, relationships are so, so crucial. They take care of you, but also it just gives you purpose, right? And if you're silently struggling with either issues related to low testosterone, or you're struggling with issues related to erectile dysfunction, which is making you pull back from those relationships that has a profound impact on the overall quality of your life is what you're saying. Absolutely. Absolutely. Well, I can see why this is critical. And it's not just about sex. It's not just about your mood or your energy. It's about your overall health. Exactly right. Hey, you want to be there as long as you can for your partner, for everybody, for yourself. So I think that's one of the reasons you should pay attention to this. Again, this can be like a check engine, right? That if erections are not as good, it's not just a convenience issue. This also may be sort of a sense of how you're doing it. So you should talk to your partner, talk to your doctor, go to a doctor, and get evaluated. Because I think there's some powerful insights you can get. And there's a lot that can be done. You do a lot of work in male fertility. And I'd love to have you speak to both what we might find surprising about the issues that you're seeing with male fertility. And if you're not even thinking about having children right now, why is male fertility an important thing to pay attention to? Yes. So I'm super passionate about male fertility as well. And there's been lots of studies that show that sperm counts are going down globally. So there's a famous study in the 90s that suggested this. It was very criticized. They updated it 20 years later, still somewhat criticized. And then just a couple years ago, they did one of the biggest updates they've ever done and showed this all over the world. So in Western countries, Eastern countries, really every continent we see this decline in sperm counts. And obviously the question is why? So I think if you're a male, you should definitely care that our sperm counts are going down. And it's still somewhat controversial how fast that declines, although the data suggests that it's accelerating in the last probably 20 years. We also see declines in testosterone levels. We see changes in pre-burtled timing and boys higher risk of testous cancer. So I think male reproductive health is declining. So even if you're not sort of immediately planning for pregnancy, there's so much that we can do to help optimize fertility that I think that you should be aware and kind of get a sense of where you are to get it checked out because it gives us an opportunity to sort of improve things. I think one of the problems just from an education standpoint, when you look at couples that are having problems with infertility about half the time there's a male factor. But at a societal level, usually everybody thinks that all fertility is related to female partner issues. And so a lot of times the males never evaluate it. In this country, probably a third of the time, a male is never seen by a specialist, never checked bypass to go through IVF, for example, which is very powerful, very effective, but it kind of removes the opportunity to try and optimize the male to try and figure out what's going on. Some things can be corrected. sperm counts are also very tied to overall health. And so it may also be kind of a check engine. light. Your sperm counselor, what else is going on? What do we need to check out? Is there something really dangerous going on? There's different anatomic factors we can look at. We can measure hormonal health and optimize that. Look at their overall lifestyle factors. Look at different medications are on. Looking at different health conditions. So I think the earlier you can do that the better because what we found is that when men come in to see us, they've already been struggling with their partners for a year or more. And they don't want us to do anything because they don't want to wait any longer. Takes two to three months to make a sperm, but they wanted to get pregnant a year ago. So they don't want to wait two months for a surgery or a pill or anything. They're ready to just go. And so I think that's really a disservice to men to male reproduction because we can't really fix things. They just put all the burden on women. We've seen sort of an abundance of awareness of male fertility. There's a lot of home testing now to make it easier for men to see where they are. So you don't have to go to a doctor anymore. You don't have to send patients to like bathrooms to collect things that are super uncomfortable. There's no question. So now you can just do it at home. You get the results immediately. It's very personal, very private. And I think that's really done a great job for awareness of this and also just making it more accessible for everybody. Dr. Eisenberg, I want to make sure I followed the statistics and I got them right. Okay. So in 50% of the cases where there are fertility issues, it is a male issue, not a female issue. Right. Well, so what I should say is that it's all causes 50%. So that's 30% only men, 20% men and women together. But there is a male factor that we can optimize in half of these cases of fertility problems. Wow. So in 50% of fertility problems, it's either the dude or it's the woman and the dude together. And what you're saying is that what happens for a lot of couples is when you are having fertility issues, you focus on the woman, you race to IVF, instead of also looking at this 50%, which is there could be a lot of issues with your partner. That's right. Wow. Yeah. And again, there's so much that can be done. I think there's a standard evaluation. And if you look at guidelines like by the American Society of Reproductive Medicine, American Eurologic Association, everybody says you should check out both members of the couple simultaneously. But for different reasons, I think a lot of it is just knowledge from patients, from some of the providers. They just never think to check the man out. So it's a huge opportunity. And I think disservice to men. Wow. Hey, women. It's a disservice to everybody. I'm really happy that you explained it like that. So if you're having fertility issues, both of you should get checked out immediately. Can you talk about men's pelvic floor health? Why is it important to pay attention to and what is pelvic floor health? So there's a lot of muscles in the pelvic floor that really control everything. So they control erections, ejaculation, orgasm. They're also involved in urine control, bowel control. So it's very important to sort of be aware of how important they are. And a lot of times we just take it for granted. But there are some times where it can lead to problems. So there can be chronic pelvic pain. We see sometimes some scrotal pain is due to spasms and some of these muscles after pelvic surgery, like prostate removal for prostate cancer. For example, we teach men how to do some pelvic floor exercise to strengthen some of these muscles to try and regain some of the urinary control that sometimes compromise after surgery. So I think that there's a lot that can be done. And I think just having some understanding awareness that it's very important for men and for women to know that. Let's talk about pain. So as you age, do you start to drip? Like, do you pee more at night? Like, what do you do if your partner is getting up three or four times a night to pee? So yeah, your nation definitely changes with age. So we do see that. Then men wake at night, I think there's different reasons for that. You know, that bladder is under a lot more pressure because as we age, the prostate gets bigger. So the resistance of the outflow track, if we go back to this model, which I think is super helpful. So we see we make urine, it collects in the bladder, then it goes through this channel, the urethra out. And so this is the prostate. So you can imagine, as we age, the prostate can get bigger out, but it can also get bigger in. So this can narrow this channel and make it harder to empty. So the bladder has to work a little harder. It gets spastic. Sometimes it can reduce capacity, the ability to fill. And so sometimes we just have to wake up at night. Sometimes at night, like with obstructive sleep apnea or other things, we produce more urine at night. And so that also makes us have to wake up more. So once a night's pretty normal, but when it starts to be a little more destructive, two, three, four times, I think definitely you want to get evaluated because there are different medications that can help with that, different treatments that are available. So there are things that can be done. What about standing there and it's just taking a lot of time for anything to come out? It depends how much that bothers you. I think if you empty your bladder, it's probably not a problem. But if it does bother you, bothers your partner. I mean, there's things that can be done. I think one of the biggest issues that we see if the prostate resistance is harder for everything to relax on time, to contract on time. And so there's medications that can help optimize that a little bit too. So that's another option. If you're having trouble with frequency more emptying your bladder, could it be a sign of a deeper issue with the prostate? Anytime men have any urinary symptoms, I think we always want to evaluate to make sure there's nothing we're missing. So we usually check a urine test to make sure there's no signs of infection inflammation. Those can certainly be some of the symptoms that we see. A lot of times, again, depending on the age, we'll check the prostate-specific antigen or PSA. And that gives us a sense of how big the prostate is, but also the screening test for prostate cancer. Usually, this is more of a quality of life issue, not a life and death issue. So I think that's what men should be aware of. Your partners should be aware of that as well. But talk to your doctor about it. I think that it is something that men just kind of think is normal and they just tend to live with it. And if it's not worth a pill, you know, maybe that's fine, but there's usually treatments that are available that are very effective. That's super helpful. Are there any warning signs that we should be aware of that may indicate prostate cancer? Usually, most commonly prostate cancer is diagnosed just with a blood test. So it tends to be asymptomatic and it's just kind of done by screening. So if there's a strong family history, usually we start screening a little bit earlier, but otherwise, you know, there's guidelines about starting it in your 50s just with an annual or semi-annual test. Terrific. That's so helpful. You have taught us so much today. Dr. Eisenberg, if the person listening does just one thing after hearing all of this, what do you think the most important action to take is? I guess the most important thing I would say is just to be aware of your health. Realize that you have agency that you can improve things. Take a, you know, kind of an internal inventory because we're not just talking about sort of quality of life. I think some of these things could have real impacts on longevity too. Try and be more active. If you haven't seen a doctor before, I think you have to go every year, but I think getting checked is important to find out, you know, what your blood pressure is, what your cholesterol is because all those things tie so closely to some of these issues that we talked about testosterone, sexual function, reproductive function. I think those are also going to be really crucial. Just know that you can improve them. Dr. Eisenberg, what are your parting words? First, I want to thank you for just highlighting men's health. I think men's hormonal health, sexual health, reproductive health. I think it's so important. It's not talked about, but I just want to let everybody know that this is a very important topic and something that a lot needs to be done about and can be done about. Well, what I love about your work and the way that you talk about it is you make me believe that you can do something. The fact that when I asked about erectile dysfunction, you're like, oh, no, no, you got to pee this I can make it hard. Oh, no, no, no, no, it's a testosterone. We can work this out and knowing that you don't have to live in shame. You don't have to live feeling low mood, low energy that there may be and there probably are underlying conditions that medical experts like you have incredible tools and different medications that can truly help you not only feel better, but live a more fulfilling life. I just think that's so cool. It is really cool. Well, thank you for taking time out of your schedule. Thank you for doing the research that you do and thank you for coming here and educating all of us and giving us the ultimate guide in my opinion to male hormone health and also helping us understand why it actually matters. I love that it's tied to longevity. I love that it's tied to a sense of agency over yourself and I love that there are things that you can do for every issue that we talked about. So thank you. Thank you, Mel. This has been a pleasure. You're welcome and thank you. Thank you for making time to listen to this. Thank you for being generous with Dr. Eisenberg's teaching and all the time and wisdom that he poured into you and thank you for sharing this with the men in your life that you care deeply about and in case no one else tells you I wanted to be sure to tell you that I love you and I believe in you and I believe in your ability to create a better life. I'm going to send this to my husband, to my brother. Any man that you send this to, this could help him create a better life. And so thank you, thank you, thank you for making the time to be here. Alrighty, I'll see you in the next episode. I'll welcome you in the moment you hit play. In fact, I, in fact, Dr. Eisenberg, reproductive health and okay, go ahead. Let's do this. He leads Stanford's male reproductive medicine and surgery program and serves, and serves of the International Aesospermia Center, which is basically their male infertility center. I want to say, let me say International Aesos. Dr. Michael Eisenberg, the head of Stanford met Dr. Eisen, wait here, uh, hold on a second. Oh, and one more thing. And no, this is not a blooper. This is the legal language. You know what the lawyer's right and what I need to read to you. This podcast is presented solely for educational and entertainment purposes. I'm just your friend. I am not a licensed therapist and this podcast is not intended as a substitute for the advice of a physician, professional coach, psychotherapist, or other qualified professional. Got it? Good. I'll see you in the next episode. (upbeat music) - SiriusXM podcasts.